Senior Registration Form 2026/27
First Name
Last Name
Email
Phone Number
Address
Postcode
Date of Birth - using following format - e.g.07/03/21
Name of Emergency Contact 1
Emergency Contact 1 Mobile Number
Relationship to Club Member
Name of Emergency Contact 2
Emergency Contact 2 Mobile Number
Relationship to Club Member
Medical Information - ALL club members are required to provide medical information as accurately as possible. You must advise the club immediately of any changes to the information you provide.
Do you have any long term illnesses or injuries we should be aware of?
Yes
No
If you have answered yes to above please provide details below
Please provide details of any regular medication we should be aware of:
As far as you are aware, are you allergic to any medication?
Yes
No
If you have answered yes to above please provide details below
Membership Type
Full Time Student/Unemployed
Senior Member
Back to Hockey Group
Please tick any Voluntary Roles you are interested in
Junior Coaching (Monday Night)
Youth/Senior Coaching
Umpiring
Administration (eg Umpiring Sec. / Fixtures Sec)
Organising Fundraising/Social Events
N/A
Add any additional volunteering details below
I have read and agree to the Terms & Conditions set out in the Member Declaration on the Club Website. https://www.rhonddaladieshockeyclub.com/member-declaration
Yes
No
I have read and agree to the Terms & Conditions set out in the Privacy Policy on the Club Website. https://www.rhonddaladieshockeyclub.com/policiesprocedures
Yes
No
Your Signature
Date
Submit
Senior Registration Form 2026/27